Cleaner Pre-Hospital/EMS PCR reports
in SOAP or CHART.
Incident Information
Location
| Address | |
| City | |
|
W3W
///
|
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|
GPS
lat
|
|
Apparatus and Response
| Apparatus | ||
| Response | or | |
| Transport | or | |
| Disposition |
Personnel
| Name | Role |
Dispatch info
Patient Information
Name
| First | Middle | Last |
Phone
| Phone #1 | Phone #2 |
Address
| Address | |
| City |
Age, Sex, Weight
| Month | Day | Year | ||
| Birthdate | Age: | |||
| Weight | kgs lbs | |||
Subjective Information
Pt's chief complaint:
OPQRST
|
Onset:
|
Provokes:
|
||
|
Quality:
|
Radiates:
|
||
|
Severity:
|
Time:
|
ADMITS AND DENIES
Fever
Headache
Dizziness
Blurred Vision
Runny Nose
Loss of Smell
Loss of Taste
Sore Throat
Cough
Nausea
Vomiting
Diarrhea
Chest Pain
Difficulty Breathing
Abdominal Pain
Pelvic Pain
Leg Pain
Arm Pain
Back Pain
Neck Pain
LOC
Alcoholic Beverages
Recreational Drugs
Pregnancy
Fatigue
Body Aches
Recent Travel
Recent Illness
Recent Trauma
Recent Surgery
Fever
Headache
Dizziness
Blurred Vision
Runny Nose
Loss of Smell
Loss of Taste
Sore Throat
Cough
Nausea
Vomiting
Diarrhea
Chest Pain
Difficulty Breathing
Abdominal Pain
Pelvic Pain
Leg Pain
Arm Pain
Back Pain
Neck Pain
LOC
Alcoholic Beverages
Recreational Drugs
Pregnancy
Fatigue
Body Aches
Recent Travel
Recent Illness
Recent Trauma
Recent Surgery
| Past medical history: | |
| Rx Medications: | |
| OTC Medications: |
Other: |
| Allergies: |
Other: |
| Hospital/Destination Preference: |
Reason for choice:
|
Objective Information
Age:
Approx. Weight:
kgs
lbs
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Teeth Trauma
Tongue Trauma
Gag Reflex
Smells of alcohol
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
JVD
Tracheal Deviation
Sub Q Air
Acc Muscle Usage
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Sub Q Air
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Equal Rise and Fall
Retractions
Acc Muscle Usage
Barrel Chest
Pacemaker
Chest Scar (zipper)
Flail Segment
Sub Q Air
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Distention
Guarding
Rigidity
Other
Urinary Incontinence
Hematuria
Feces Incontinence
Hematochezia
Melena
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Genital Trauma
Priapism
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
CMS
Weakness
Numbness
Tingling
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
CMS
Weakness
Numbness
Tingling
Carpal Pedal Spasms
Other
Inline
Deformity
AMS
Signs of Intoxication
Significant Mechanism
CTLS Tenderness
Neuro Deficits
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Other
Stroke Test
Symmetrical Smile
Tongue Aligned
Arm Drift
Slurred Speech
Normal Gait
Repetitive Statements
Combative
Confused
Hallucinations
Tremors
Hemiparesis
Paraplegia
Quadriplegia
Other
Signs of other causes of altered mentation
Signs of other causes of altered mentation
Signs of causes of altered mentation
1 minute APGAR
5 minute APGAR
| Mentation: |
|
|
General Impression:
|
ABC's
| Airway: |
| Breathing: |
|
| Circulation: |
|
||||||||||
|
HEAD
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Teeth Trauma
Tongue Trauma
Gag Reflex
Smells of alcohol
Other
Pupils Left: Right:
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Teeth Trauma
Tongue Trauma
Gag Reflex
Smells of alcohol
Other
ANTERIOR NECK
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
JVD
Tracheal Deviation
Sub Q Air
Acc Muscle Usage
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
JVD
Tracheal Deviation
Sub Q Air
Acc Muscle Usage
Other
SHOULDER
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Sub Q Air
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Sub Q Air
Other
CHEST
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Equal Rise and Fall
Retractions
Acc Muscle Usage
Barrel Chest
Pacemaker
Chest Scar (zipper)
Flail Segment
Sub Q Air
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Equal Rise and Fall
Retractions
Acc Muscle Usage
Barrel Chest
Pacemaker
Chest Scar (zipper)
Flail Segment
Sub Q Air
Other
LUNG SOUNDS
| UL | UR | LL | LR | |
| Clear | ||||
| Diminished | ||||
| Absent | ||||
| Inspiratory Wheeze | ||||
| Expiratory Wheeze | ||||
| Rhonchi | ||||
| Crackles/Rales |
| Comment |
ABDOMEN
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Distention
Guarding
Rigidity
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Distention
Guarding
Rigidity
Other
GU/GI
Urinary Incontinence
Hematuria
Feces Incontinence
Hematochezia
Melena
Other
Urinary Incontinence
Hematuria
Feces Incontinence
Hematochezia
Melena
Other
PELVIS
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Genital Trauma
Priapism
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Genital Trauma
Priapism
Other
LEGS
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
CMS
Weakness
Numbness
Tingling
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
CMS
Weakness
Numbness
Tingling
Other
ARMS
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
CMS
Weakness
Numbness
Tingling
Carpal Pedal Spasms
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
CMS
Weakness
Numbness
Tingling
Carpal Pedal Spasms
Other
CTLS SPINE
Inline
Deformity
AMS
Signs of Intoxication
Significant Mechanism
CTLS Tenderness
Neuro Deficits
Other
Inline
Deformity
AMS
Signs of Intoxication
Significant Mechanism
CTLS Tenderness
Neuro Deficits
Other
BACK
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Other
Deformity
Bruising
Abrasion
Puncture
Burn
Tenderness
Laceration
Incision
Swelling
Active Bleeding
Rash
Other
NEURO
Stroke Test
Symmetrical Smile
Tongue Aligned
Arm Drift
Slurred Speech
Normal Gait
Repetitive Statements
Combative
Confused
Hallucinations
Tremors
Hemiparesis
Paraplegia
Quadriplegia
Other
Stroke Test
Symmetrical Smile
Tongue Aligned
Arm Drift
Slurred Speech
Normal Gait
Repetitive Statements
Combative
Confused
Hallucinations
Tremors
Hemiparesis
Paraplegia
Quadriplegia
Other
MENTAL STATUS
|
Appearance/Behavior
|
Calm
Clean
Groomed
Cooperative
Confused
Agitated
Restless
Lethargic
Calm
Clean
Groomed
Cooperative
Confused
Agitated
Restless
Lethargic
|
|
IR/ST/LT Memory
|
Imm. Recall
Short Term
Long Term
Memory intact based on conversation
Imm. Recall
Short Term
Long Term
Memory intact based on conversation
|
|
Cognition/Concentration
|
WORLD
$3.75
Serial 7s
Mickey Mouse
Concentrates on questions and answers appropriately
WORLD
$3.75
Serial 7s
Mickey Mouse
Concentrates on questions and answers appropriately
|
|
Insight/Judgement
|
Makes a plan
Accepts a plan
Problem solves
Makes a plan
Accepts a plan
Problem solves
|
|
Thoughts
|
Linear
Logical
Tangential
Psychotic
Linear
Logical
Tangential
Psychotic
|
|
Speech
|
Clear
Appropriate words
Slurred
Mumbles
Clear
Appropriate words
Slurred
Mumbles
|
ENVIRONMENT
|
Home
|
Clean
Cluttered
Lives alone
Lives with others
Clean
Cluttered
Lives alone
Lives with others
|
|
People Present
|
Family
Friends
Is alone
Family
Friends
Is alone
|
|
Weather
|
Hot
Cold
Wet
High altitude
Hot
Cold
Wet
High altitude
|
MOBILITY
|
Current Mobility
|
Able to walk
With assistance
Wheelchair
Walker
Cane
Confined to bed
Able to walk
With assistance
Wheelchair
Walker
Cane
Confined to bed
|
PT PROPERTY
OTHER
Choose Assessment Specific Documentation
|
Cardiac Diabetes Environmental Gastrointestinal Neurological |
OB GYN Pain Pyschological Respiratory Shock Toxicological Trauma Other |
Assessment Specific Documentation
Angina, AMI, Chest Pain, Dysrhythmia, Cardiogenic Shock
| Peripheral Edema | |
| Ascites | |
| JVD | |
| Back Pain |
Check your protocols for medications and procedures for this assessment
Document why a medication or procedure did not happen.
Document why a medication or procedure did not happen.
Double check these are documented in your objective or plan sections
|
|
|
Hypertension
| Compliant with medications | |
| Photophobia | |
| Cardiogenic complaints | |
| Meningeal signs/symptoms |
Double check these are documented in your objective or plan sections
|
|
|
Hyperglycemia
| History of diabetes | |
| Compliant with medications | |
| Last oral intake | |
| Duration of symptoms | |
| Signs of dehydration | |
| Signs of abdominal pain |
Signs of other causes of altered mentation
| Alcohol | |
| Seizures | |
| Infection | |
| Overdose | |
| Uremia | |
| Trauma | |
| Psychological | |
| Shock | |
| Stroke |
Double check these are documented in your objective or plan sections
|
|
|
Hypoglycemia
| History of diabetes | |
| Compliant with medications | |
| Type of insulin | |
| Insulin schedule | |
| Last oral intake | |
| Duration of symptoms | |
| Nutritional status |
Signs of other causes of altered mentation
| Alcohol | |
| Seizures | |
| Infection | |
| Overdose | |
| Uremia | |
| Trauma | |
| Psychological | |
| Shock | |
| Stroke |
Double check these are documented in your objective or plan sections
|
|
|
Altitude Sickness
| Home altitude or city | |
| Time at current altitude |
Double check these are documented in your objective or plan sections
|
|
|
Bite / Sting
| Time of envenomation | |
| Type of envenomation | |
| Identification of animal | |
| Activity since envenomation | |
| Envenomation site |
Double check these are documented in your objective or plan sections
|
|
|
Burn
| Method of burn | |
| Percentage of burn area | |
| Depth of burn | |
| Location of burn | |
| Respiratory burn |
Check your protocols for medications and procedures for this assessment
Document why a medication or procedure did not happen.
Document why a medication or procedure did not happen.
Double check these are documented in your objective or plan sections
|
|
|
Carbon Monoxide, Smoke Inhalation
| Environmental factors | |
| Type of fire | |
| Duration of exposure | |
| Environmental CO readings | |
| CO-oximetry readings |
Double check these are documented in your objective or plan sections
|
|
|
Hypothermia, Frostbite
| Ambient temperature | |
| Body temperature | |
| Location of injury | |
| Duration in environment | |
| Warming method |
Double check these are documented in your objective or plan sections
|
|
|
Hazmat Exposure
| Type of exposure | |
| Duration of exposure | |
| Pre-arrival treatment | |
| ID of substance | |
| Decontamination method |
Check your protocols for medications and procedures for this assessment
Document why a medication or procedure did not happen.
Document why a medication or procedure did not happen.
Double check these are documented in your objective or plan sections
|
|
|
Hyperthermia
| Ambient temperature | |
| Body temperature | |
| Cooling method | |
| Precipitating factors |
Double check these are documented in your objective or plan sections
|
|
|
Ab Pain, Kidney Stone, UTI
| GI/GU history | |
| GI/GU surgeries | |
| Nausea | |
| Vomiting | |
| Diarrhea | |
| Fever | |
| Referred pain | |
| Associated trauma |
Check your protocols for medications and procedures for this assessment
Document why a medication or procedure did not happen.
Document why a medication or procedure did not happen.
Double check these are documented in your objective or plan sections
|
|
|
Diarrhea, Vomiting, Dehydration
| Recent travel | |
| Frequency/Duration | |
| Dietary changes | |
| GI/GU history | |
| Description of emesis/stool |
|
| Origin | |
| Skin temperature |
Double check these are documented in your objective or plan sections
|
|
|
GI Bleed
| History of ulcers | |
| History of alcohol abuse | |
| Description of emesis/stool |
|
| Origin |
Double check these are documented in your objective or plan sections
|
|
|
Nausea, Vertigo, Dizzy, Cold/Flu-like, Generalized Weakness
| Nystagmus | |
| Associated trauma | |
| Description of emesis | |
| Provoking factors (makes it worse) |
Check your protocols for medications and procedures for this assessment
Document why a medication or procedure did not happen.
Document why a medication or procedure did not happen.
Double check these are documented in your objective or plan sections
|
|
|
ALOC, Dementia, ETOH, AMS
| Nystagmus | |
| Double vision | |
| Ataxia | |
| Origin |
Signs of causes of altered mentation
| Alcohol | |
| Seizures | |
| Infection | |
| Diabetes | |
| Overdose | |
| Uremia | |
| Trauma | |
| Psychological | |
| Shock | |
| Stroke |
Double check these are documented in your objective or plan sections
|
|
|
CVA, TIA, Stroke
| Aphasia | |
| Dysphasia | |
| Facial droop | |
| Arm drift | |
| Nystagmus | |
| Time of onset |
Double check these are documented in your objective or plan sections
|
|
|
Syncope, Near Syncope
| Events prior to episode | |
| Previous episodes | |
| Trauma related | |
| Vertigo/Dizziness | |
| Seizure activity | |
| Good fluid intake |
Double check these are documented in your objective or plan sections
|
|
|
Seizure
| History of seizures | |
| Compliant with medication | |
| Aura | |
| Oral trauma | |
| Incontinence | |
| Meningeal signs/symptoms | |
| Description of seizure activity | |
| Description of postictal period |
Double check these are documented in your objective or plan sections
|
|
|
Childbirth, Pregnancy, Pre-eclampsia
| Description of contractions/abdominal pain |
|
| Duration/timing of contractions | |
| Water broke | |
| Description of amniotic fluid | |
| Gravida (# of pregnancies) | |
| Para (# of live births) | |
| Due date | |
| Known problems | |
| Prenatal care | |
| Social support during pregnancy |
Double check these are documented in your objective or plan sections
|
|
Newborn Care, Birth
| Due date | |
| Time of birth | |
| Type of presentation | |
| Sex | |
| Time cord cut | |
| Placenta intact | |
| Meconium |
1 minute APGAR
| Activity | |||
| Pulse | |||
| Grimace | |||
| Appearance | |||
| Respiration |
5 minute APGAR
| Activity | |||
| Pulse | |||
| Grimace | |||
| Appearance | |||
| Respiration |
Double check these are documented in your objective or plan sections
|
|
|
Miscarriage, Vaginal Bleeding
| Possibility of pregnancy | |
| Due date | |
| Last menstrual period | |
| Volume of blood loss | |
| Description of blood/discharge | |
| History of OB/GYN complications | |
| Trauma related | |
| Domestic abuse related |
Double check these are documented in your objective or plan sections
|
|
Non-traumatic Pain
| Chronic vs Acute | |
| Frequency / Duration | |
| Location of pain | |
| Distribution of pain |
Check your protocols for medications and procedures for this assessment
Document why a medication or procedure did not happen.
Document why a medication or procedure did not happen.
Double check these are documented in your objective or plan sections
|
|
|
Behavior, Psychiatric
| Suicidal thoughts | |
| Suicidal plan | |
| Ability to carry out plans | |
| History of depression | |
| History of behavioral problems | |
| Presence of alcohol/drugs | |
| Onset | |
| Compliant with medications |
Double check these are documented in your objective or plan sections
|
|
|
Airway Obstruction, Respiratory Arrest
| Duration of episode | |
| Pre-arrival treatment | |
| History of previous episodes |
Double check these are documented in your objective or plan sections
|
|
|
Respiratory Distress
| Duration of episode | |
| Pre-arrival treatment | |
| Description of previous episodes | |
| Previous intubations/ICU | |
| JVD | |
| Hepato-jugular reflex | |
| Peripheral edema | |
| Ascites |
Double check these are documented in your objective or plan sections
|
|
|
Hypovolemic, Neurogenic, Septic Shock
| JVD |
Double check these are documented in your objective or plan sections
|
|
|
Overdose, Illegal Substance, Medications
| Type of ingestion/poisoning | |
| ID of substance | |
| Intentions | |
| Poison Control contacted |
Double check these are documented in your objective or plan sections
|
|
|
TRAUMA
| Mechanism of injury | |
| Safety equipment used | |
| Non-accidental |
Check your protocols for medications and procedures for this assessment
Document why a medication or procedure did not happen.
Document why a medication or procedure did not happen.
Double check these are documented in your objective or plan sections
|
|
|
Epistaxis, Nose Bleed
| History of hypertension | |
| Prescribed anticoagulant | |
| Previous carterizations | |
| Associated trauma |
Double check these are documented in your objective or plan sections
|
|
Fever
| Meningeal signs/symptoms |
Double check these are documented in your objective or plan sections
|
|
|
Sexual Assault
| Associated trauma | |
| Measures taken to preserve evidence |
Double check these are documented in your objective or plan sections
|
|
|
Allergic Reaction
| Hives (urticaria) | |
| Red patches (erythema) | |
| Angioedema | |
| Rhinorrhea | |
| Cause of exposure (bite, meds, food, ...) |
|
| History of similar events |
Double check these are documented in your objective or plan sections
|
|
|
Traffic Accident, Motor Vehicle Collision
|
Type
|
|
|
Direction
|
Northbound
Southbound
Eastbound
Westbound
Northbound
Southbound
Eastbound
Westbound
|
|
Speed
|
|
|
Weather
|
Clear
Dry Road
Icy Road
Raining
Snowing
Fog
Clear
Dry Road
Icy Road
Raining
Snowing
Fog
|
|
Impact
|
Frontal
Rear-end
Lateral
Rotational
Rollover
Angular
Frontal
Rear-end
Lateral
Rotational
Rollover
Angular
|
|
Dash
|
Intact
Damaged
Intact
Damaged
|
|
Windshield
|
Intact
Star pattern
Damaged
Intact
Star pattern
Damaged
|
|
Steering Wheel
|
Intact
Deformed
Intact
Deformed
|
|
Intrusion
|
No intrusion
Mild
Moderate
Significant
No intrusion
Mild
Moderate
Significant
|
|
Airbags
|
No airbags
Airbags deployed
No airbags
Airbags deployed
|
|
Pt Position
|
Driver
Front Passenger
Rear Passenger
Driver
Front Passenger
Rear Passenger
|
|
Seatbelt
|
Secured with seatbelt
Secured with seatbelt
|
|
MOI
|
No injury
Airbag injury
Into steering wheel
Up and over
Down and under
Ejection
No injury
Airbag injury
Into steering wheel
Up and over
Down and under
Ejection
|
|
Damage
|
No damage
Mild
Moderate
Significant
No damage
Mild
Moderate
Significant
|
Assessment Information
Assessment:
Severity:
Plan Information
Choose procedures and a list will form below
Response
Arrival
Exam
Vital Signs
GCS
O2
IV/IO
Blood Glucose
CPR
Capnography
Medication
Pain Scale
Cranial Nerve
Airway OPA/NPA
Airway OETT/NETT
Airway Laryngeal
Airway Cric
Airway Check
Suction
Orders
EKG
EKG Sent
Defib/Pacing
Bandage
Splinting
Extrication
Spinal
To Cot
Refusal
Pt Advised
In Ambulance
Terminate Care
Transport
Radio Report
Destination
Transfer Care
End of Contact
Other
Report
Create Report
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